PURPOSE To demonstrate the sustained efficacy of stent-graft exclusion of a pelvic arteriovenous fistula (AVF) in a woman who became pregnant after treatment. CASE REPORT An iatrogenic iliac arteriovenous fistula caused by redo surgery for a herniated disk in a 23-year-old woman was successfully treated with percutaneous endoluminal exclusion. Intravascular ultrasound was particularly useful for localization of the fistula during the procedure. The patient subsequently became pregnant, and serial Doppler studies were used to monitor the stent-graft until the uneventful delivery of twins by Caesarian section. At 36 months after endograft implantation, the patient has no complaints relative to the device. CONCLUSIONS Uncomplicated twin pregnancy following stent-graft repair of an AVF in the pelvis appears feasible.
Endovenous Laser Thermal Ablation (EVTA) is a new, minimally invasive technique for treating the incompetent saphenous veins and their tributaries. Although the safety and efficacy of this technique is well established, there is no standardization of the energy needed to ablate these veins. In almost all the studies with EVTA the recanalization rate ranges from 2% to 12%. The main parameter influencing vein recanalization seems to be the delivered energy at the vein wall (Joule/cm). Other parameters have also been taken under consideration to explain early and late vein recanalization after endovenous thermal ablation such us vein diameter, different Laser Wavelengths, modality mode to deliver energy at the vein wall (pulsed/continuous mode), quality of the optical fiber, obesity and hemodynamic type of the saphenofemoral junction 1-6. Clinical data based on histopathologic specimen analysis after EVTA has shown that the wall damage is total and not reversible. However, there are not enough data to determine a standardization of the energy that can produce such effect limited to the vein wall without other side effects to the perivenous tissues. Regarding energy, a recent prospective study demonstrated that higher dosing of laser energy (30 Watt compared with 15 Watt) shows a 100% immediate success rate and a significantly reduced recanalization rate during a 12 month follow-up (97% vs 82,7%) 1. Although parameters influencing failure and recanalization rates of EVTA are still to be determined the failure seems to be related to the administration of low laser fluences 3. Other studies were undertaken to establish the incidence of early recanalization after EVTA and to study the histopathologic features of reperfused and excised GSV. Early recanalization requiring retreatment is observed in less than 10% of GSV after EVTA. The histopathologic pattern mimics recanalization after thrombotic occlusion 7. Comparison of low rates of delivered energy (around 33 J/cm2) to the vein wall were used to study their success rate and for early retreatment of the failed procedures. There were no significant differences in mean total energy or unit energy applied among successful, failed, and repeat treatments. EVTA with lower energy appeared to be safe and effective. Larger GSV diameter was associated with early treatment failures 8. Further studies sustained the efficacy and good results of EVTA of GSV with low energy, using a 980 nm diode laser at 11 watts in continuous mode. Mean energy applied per treated GSV length of 35.16 J/cm (mean laser fluence of 9.82 J/cm2) appeared adequate, resulting in 0% recanalization and a low number of minor complication rates 9. In contrast with the previous statements the hypothesis that higher energy dose improves procedural success without increasing complications was prospectively evaluated by per
Background: Knee arthroscopy, the most common orthopedic operation worldwide, carries a definite risk for deep venous thrombosis; however, postsurgical thromboprophylaxis is not routinely recommended. Objective: To evaluate whether low-molecular-weight heparin (LMWH) better prevents deep venous thrombosis and does not cause more complications than graduated compression stockings in adults having knee arthroscopy. Design: Assessor-blind, randomized, controlled trial. Setting: The Department of Knee Surgery, Abano Terme Clinic, Abano Terme (knee surgery, random assignment, and bleeding event survey), and the Unit of Angiology, University Hospital of Padua, Padua (efficacy outcomes evaluation, follow-up, data management, and analysis), Italy. Patients: 1761 consecutive patients undergoing knee arthroscopy between March 2002 and January 2006. Intervention: Patients were randomly assigned to wear full-length graduated compression stocking for 7 days (660 patients) or to receive a once-daily subcutaneous injection of LMWH (nadroparin, 3800 anti-Xa IU) for 7 days (657 patients) or 14 days (444 patients). The data and safety monitoring board prematurely stopped the 14-day heparin group after the second interim analysis. Measurements: Combined incidence of asymptomatic proximal deep venous thrombosis, symptomatic venous thromboembolism, and all-cause mortality (primary efficacy end point) and combined incidence of major and clinically relevant bleeding events (primary safety end point). All patients had bilateral whole-leg ultrasonography at the end of the allocated prophylactic regimen or earlier if indicated. All patients with normal findings were followed for 3 months, and none was lost to follow-up. Results: The 3-month cumulative incidence of asymptomatic proximal deep venous thrombosis, symptomatic venous thromboembolism, and all-cause mortality was 3.2% (21 of 660 patients) in the stockings group, 0.9% (6 of 657 patients) in the 7-day LMWH group (absolute difference, 2.3 percentage points [95% CI, 0.7 to 4.0 percentage points]; P = 0.005), and 0.9% (4 of 444 patients) in the prematurely stopped 14-day LMWH group. The cumulative incidence of major or clinically relevant bleeding events was 0.3% (2 of 660 patients) in the stockings group, 0.9% (6 of 657 patients) in the 7-day LMWH group (absolute difference, −0.6 percentage point [CI, −1.5 to 0.2 percentage points]), and 0.5% (2 of 444 patients) in the 14-day LMWH group. Limitations: The study was not double-blind or double-dummy. Almost half of the events making up the composite outcome measure were distal deep venous thromboses. Stockings were used instead of placebo because of local prophylaxis policies. Conclusion: In patients undergoing knee arthroscopy, prophylactic LMWH for 1 week reduced a composite end point of asymptomatic proximal deep venous thrombosis, symptomatic venous thromboembolism, and all-cause mortality more than did graduated compression stockings.
Introduction: The common belief about the beneficial effects of water immersion on leg veins function is mostly based on empirical experiences. We have performed a series of tests to evaluate the real effects of the increase of interstitial pressure generated by water immersion on the leg veins morphology, venous return and veno-lymphatic drainage. Methods: The immediate effects of water hydrostatic pressure (wHP) on vein morphology and venous flow were evaluated by underwater duplex sonography (DS) during immersion. The immediate effects of HP on calf volume and ejection fraction (EF) were evaluated by underwater strain gauge pletysmography (SGP). The effects of prolonged immersion on leg volume and on subcutaneous tissues were evaluated by both water displacement volumetry (WDV) and DS. Results: The caliper of normal and varicose veins were immediately and significantly reduced by immersion (p.004 and p 0.012 for the femoral and great saphenous veins, respectively). Simultaneously, the spontaneous centripetal flow increased. In varicose legs, the reflux was reduced or even disappeared. SGP demonstrated an immediate reduction of the calf circumference and the simultaneous increase of the EF (+68.9%). Finally, a marked reduction in ankle circumference (-2.89%), subcutaneous tissue thickness (-24.35%) and leg volume (-4,2%) was demonstrated after 30’ of standing into the water. Walking into the pool for the same time resulted in an even more significant reduction of all these three parameters (-5.98%; -32.66% and -6.50%, respectively). Discussion: our results suggest that the wHP-related reduction of vein caliber is responsible for the immediate increase of the centripetal flow, the immediate reduction of the calf volume and of the reduced reflux, when present. The great reduction of the leg volume after prolonged static immersion seems to be due to the positive effects of wHP on the balance between interstitial fluid filtration and lymphatic reabsorption. A mutual enhancement between the effects of HP on interstitial fluids dynamics and those of muscle activity on EF, may explain the greater reduction of the leg volume, ankle circumference and epifascial thickness after underwater walking compared to those after static immersion. Conclusions: The possible clinical and rehabilitative implications of these findings in the treatment and rehabilitation of leg venous disorders are finally outlined.
